Elemental EM: Retropharyngeal Abscess

Authors: Moira Carroll, MD (EM Resident Physician, Icahn SoM at Mount Sinai) and Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX)

Clinical Case:

An 19 year old male comes into your ER complaining of 1 week of throat pain. He endorses intermittent fevers at home, now feels like he is significant odynophagia. He just started his senior year of high school, states that a bunch of his new friends are sick. He is up to date on his vaccinations. Review of systems is otherwise negative. On physical exam, vital signs T 38.6° C, HR 104, BP 110/62, RR 20, O2 saturation 99% on room air, he has cervical lymphadenopathy, the oropharynx is erythematous, with tonsillar exudates. Rapid strep and monospot are negative, you send a throat culture. The patient is given decadron and motrin and feels better, he is tolerating water. He is discharged with supportive care and instructions for primary care follow-up.

Some days in your fast track or pediatric emergency department you will see countless sore throats with benign features. This post is a way to start a discussion on more dangerous features of sore throats.


What if this patient was 4 years old and his mother noted crying when she tried to give him juice and “his shirt is wet with spit”?

What is the differential for sore throat? (Ref 1,2)

Differential Diagnosis for Sore Throat

  • Ludwig angina
  • Peritonsillar abscess
  • Retropharyngeal abscess
  • Epiglottitis
  • Bacterial Tracheitis
  • Bacterial pharyngitis
  • Viral pharyngitis
  • Tonsillitis
  • Mononucleosis
  • Tumor
  • Oropharyngeal trauma
  • Foreign body


What would make you consider retropharyngeal abscess? (Ref 1,2)


  • 96% are <6 years old
  • Preceding nasopharyngitis, otitis media, parotitis, tonsillitis, peritonsillar abscess
  • Dental infection and procedures
  • Upper airway instrumentation
  • Endoscopy
  • Blunt and penetrating trauma – foreign body often a fish bone
  • Ingestion of caustic substances
  • Vertebral fractures


  • Fever
  • Sore throat, dysphagia, odynophagia
  • Drooling, muffled voice, dysphonia – described as duck quack (cri du canard)
  • Neck stiffness
  • Positioning with necks extension and remaining supine, sitting makes it worse as swollen tissue can compress airway.

Physical Exam Findings:

  • Pain/limitation of neck extension/flexion (Ref 3)
  • Fever
  • Cervical lymphadenopathy
  • Trismus, Torticollis
  • Diffuse edema and erythema of posterior pharynx
  • Neck swelling (rare)
  • Tracheal rock sign – pain with moving trachea side to side
  • Symptoms disproportionate of findings should prompt further evaluation*

What are the upper airway signs that signify an impaired airway (and the need to intubate)?

  • Stridor
  • Unable to handle secretions
  • Positioning (sniffing, neck in hyperextension)
  • Voice changes

How do you diagnose retropharyngeal abscess? (Ref 1)

  • Lateral neck X-ray or CT scan
  • Anteroposterior (AP) diameter of soft tissues along anterior bodies of C1- 4 should be less than 40% of the AP diameter of the vertebral body behind it (Ref 1)


Widening of the pre-vertebral soft tissue between C2 and C7, with multiple gas foci within at the C3-C4 level. Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 30018

What is the management of a retropharyngeal abscess? (Ref 1,2)

  • Antibiotics: Most infections are polymicrobial (oral flora)
    • Clindamycin
    • High dose penicillin + Metronidazole
    • Piperacillin tazobactam
    • Ampicillin sulbactam
  • Consultant: Otolaryngology
  • Admit (often ICU)


  1. Melio FR. Upper Respiratory Tract Infections.Chapter 65, 857-870.e1 In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Edition.
  2. Rose E. Pediatric Respiratory Emergencies: Upper Airway Obstruction and Infections. Chapter 167, 2069-2080.e2. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Edition.
  3. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. 2003; 111(6 Pt 1): 1394-8.


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